Cook M, Brodeur M, Xu T
… +5 more, Danboise B, Cambron JD, Leeson B, Leeson K, Richman P
Acad Emerg Med
· 2026 Jan · PMID 41077691
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BACKGROUND AND OBJECTIVES: Telemedicine psychiatry has become increasingly prevalent in emergency medicine settings. Given the limited prior research, we evaluated the interrater agreement between emergency physicians (E...BACKGROUND AND OBJECTIVES: Telemedicine psychiatry has become increasingly prevalent in emergency medicine settings. Given the limited prior research, we evaluated the interrater agreement between emergency physicians (EPs) and telemedicine psychiatrists regarding the assessment of safe disposition for mental health patients in the emergency department (ED). METHODS: This prospective, observational study was conducted at an urban, community teaching hospital. A convenience sample of adult ED patients presenting with mental health-related complaints was included for analysis. Following their evaluations, EPs completed structured forms documenting history findings and assessments of appropriate disposition. Subsequently, each patient was evaluated by a telemedicine psychiatrist, and their assessments were recorded. Categorical data were analyzed using chi-square tests, and multivariate logistic regression was performed to control for confounding variables. Interrater agreement was assessed using Cohen's kappa (κ) statistic. RESULTS: A total of 118 subjects were enrolled; mean age was 39 ± 15 years, 48% were female, 43% Hispanic, and 47% non-Hispanic white. Among participants, 64% presented with suicidal ideation. Agreement between EPs and psychiatrists was moderate for prior suicide attempts (κ = 0.48) and substantial for prior psychiatric history (κ = 0.71), prior ED visits for psychiatric complaints (κ = 0.75), and prior inpatient psychiatric care (κ = 0.75). Agreement on current suicidal ideation was substantial (κ = 0.71), but agreement on disposition safety was fair (κ = 0.29). Multivariate logistic regression revealed no patient characteristics or historical features significantly associated with EPs recommending more conservative dispositions. CONCLUSION: Interrater agreement between EPs and telemedicine psychiatrists was fair regarding the safe disposition of ED patients with mental health complaints, with EPs tending toward more conservative assessments.
Meltzer AC, Payette C, Heidish R
… +9 more, Lagunzad I, Loganathan A, Bolden T, Friedman M, Pieri M, Huang W, DeBritz D, Luck N, Lee SM
Acad Emerg Med
· 2026 Jan · PMID 41070790
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OBJECTIVES: Rapid multiplex point-of-care (POC) PCR tests may reduce unnecessary antibiotic prescribing by quickly identifying viral etiologies in patients with acute respiratory infections (ARI). We evaluated the impact...OBJECTIVES: Rapid multiplex point-of-care (POC) PCR tests may reduce unnecessary antibiotic prescribing by quickly identifying viral etiologies in patients with acute respiratory infections (ARI). We evaluated the impact of a rapid (~15 min) multiplex PCR test on antibiotic prescribing, provider confidence, patient satisfaction, and emergency department (ED) length of stay (LOS). METHODS: We conducted a prospective, single-center study (March 2024-January 2025) enrolling adults presenting to an urban academic ED with ARI symptoms. Participants underwent rapid multiplex PCR testing (BIOFIRE SPOTFIRE Respiratory Panel), with results provided to clinicians in real time. Antibiotic prescribing, provider and patient perceptions, and ED LOS were assessed through surveys and electronic health record review. A propensity-matched control cohort was used to compare antibiotic prescribing and LOS. The primary outcome was antibiotic prescribing among patients with a confirmed viral etiology; secondary outcomes included overall antibiotic prescribing, ED LOS, and provider-and patient-reported measures. RESULTS: A total of 200 patients were enrolled (mean age 43 years; 56.5% female). Common presenting symptoms included cough (80%), congestion (65%), and sore throat (55%). Patients with confirmed viral infections were significantly less likely to receive antibiotics than those with no detected pathogen (6.5% vs. 20.2%; OR 0.28; 95% CI 0.10-0.68; p = 0.009). Overall antibiotic prescribing rates were similar between experimental and control cohorts (14.9% vs. 12.0%; p = 0.392), but median ED LOS was significantly shorter in the experimental group (4.3 vs. 6.5 h; OR 0.66; 95% CI 0.59-0.74; p < 0.001). Provider diagnostic confidence was high (76%), and most patients reported high satisfaction with testing (92%). CONCLUSIONS: Rapid multiplex PCR testing was associated with reduced antibiotic prescribing for viral infections, shorter ED LOS, high provider confidence, and high patient satisfaction. These findings support the value of ultra-rapid diagnostics for antimicrobial stewardship and patient-centered care in the ED.
Mirfazaelian H, Erfan Fazel A, Azizi N
… +3 more, Baboli KM, Masoumi R, Eftekhari M
Acad Emerg Med
· 2025 Dec · PMID 41069251
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INTRODUCTION: Ketamine is the most common medication for procedural sedation and analgesia (PSA) of pediatric patients in the emergency department (ED). Since ketamine injection is painful, some studies have assessed the...INTRODUCTION: Ketamine is the most common medication for procedural sedation and analgesia (PSA) of pediatric patients in the emergency department (ED). Since ketamine injection is painful, some studies have assessed the routes other than intravenous and intramuscular. Therefore, this systematic review aims to evaluate the details of noninjectable ketamine (NIK) administration. METHODS: The review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis for Systematic Review (PRISMA) guidelines. MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection (SCIE and ESCI), and Scopus were searched for relevant studies from inception to 3 July 2025. All English original clinical research on PSA with NIK administration in pediatric populations in the ED was included. Risk of bias and certainty of evidence (COE) were also assessed. RESULTS: From 5617 identified records, 12 studies (7 interventional and 5 observational) with a total number of 1484 patients were included. Most of the studies evaluated laceration repair among children 2-12 years of age. Seven single-center double-blinded randomized controlled trials showed that oral ketamine (5-10 mg/kg) alone or in combination with other medications (mainly midazolam) provided the desirable level of sedation (COE: very low) relative to the oral comparators. It also resulted in faster onset of action (OA) (15-35 min) and shorter duration of action (DA) (60-265 min) (COE: low). Oral and nasal ketamine studies did not report any serious adverse event (SAE) associated with invasive interventions (COE: moderate to low). CONCLUSION: Sedation with oral ketamine might have a desirable depth, faster OA, and shorter DA relative to the oral comparators. Furthermore, NIK probably showed no SAE during PSA. Nevertheless, the limited number of heterogeneous studies leaves uncertainty, highlighting the need for further research.
Acad Emerg Med
· 2026 Jan · PMID 41069084
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STUDY OBJECTIVE: Treatment strategies in severe hyponatremia aim at rapid sodium correction to prevent or treat cerebral edema but limit sodium rise to prevent osmotic demyelination syndrome (ODS). The true risk of edema...STUDY OBJECTIVE: Treatment strategies in severe hyponatremia aim at rapid sodium correction to prevent or treat cerebral edema but limit sodium rise to prevent osmotic demyelination syndrome (ODS). The true risk of edema or ODS in ED patients is unknown. METHODS: We performed a retrospective study of patients admitted to the ED of a tertiary hospital from January 2013 to December 2018 with plasma sodium ≤ 125 mmol/L. The rate of cerebral edema at presentation and the rate of ODS that developed during the stay were determined based on imaging studies and clinical evaluation. Secondary analyses looked at the association between overly rapid sodium correction (> 8 mmol/L) at 24 h, ODS risk, mortality, and length of stay. RESULTS: The primary analysis group comprised 852 patients; 318 (37%) of these presented with severe symptoms. Four patients (0.5%) with cerebral edema and 11 patients (1.3%) with ODS were detected. Alcoholism, liver disease, and malnutrition were identified as risk factors for ODS. While overly rapid correction showed no association with ODS in the primary analysis group, it became the predominant risk factor in a reduced dataset with a more accurate estimate of 24-h sodium correction. Correction rate had no impact on mortality or length of stay. CONCLUSIONS: Given the low rate of cerebral edema even in severely symptomatic patients, aggressive treatment may not be necessary in most cases. The risk to develop ODS seems to be higher than the risk of brain edema. Since we found no beneficial impact of a liberal correction strategy, current treatment limits should stay in place.
Mastrianni A, Islam S, Chawla M
… +13 more, Shunk A, Luo D, Dauber-Decker KL, Izard SM, Chiuzan C, Solomon J, Qiu M, Sanghani S, Khan S, McGinn T, Jarman AF, Diefenbach M, Richardson S
Acad Emerg Med
· 2026 Jan · PMID 41048133
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Vinson DR, Somers MJ, Middleton CE
… +10 more, Zekar L, Qiao E, Woldemariam ST, Gupta N, Poth LS, Urbania TH, Niederkohr RD, Reed ME, Sperling JD, Roubinian NH
Acad Emerg Med
· 2025 Dec · PMID 41030131
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BACKGROUND: Which advanced imaging modality-computed tomography pulmonary angiography (CTPA) or lung scintigraphy-is optimal to evaluate for suspected pulmonary embolism (PE) in pregnancy is debated. Practice patterns, p...BACKGROUND: Which advanced imaging modality-computed tomography pulmonary angiography (CTPA) or lung scintigraphy-is optimal to evaluate for suspected pulmonary embolism (PE) in pregnancy is debated. Practice patterns, prevalence of indeterminate imaging, and clinician response in contemporary community hospitals are not well understood. METHODS: This retrospective cohort study included gravid adults in the emergency department (ED) and Labor and Delivery units (LDUs) who underwent advanced PE imaging 10/1/2021-3/31/2023. We excluded patients with COVID-19. Physician preferences were compared overall and in the subset of scintigraphy-eligible cases, i.e., those with imaging ordered when scintigraphy was available (7:00 a.m.-5:00 p.m.) and not contraindicated by abnormalities on chest radiography (CXR). We reported 48-h incidence of post-indeterminacy imaging and 90-day incidence of venous thromboembolism (VTE). RESULTS: Among 315 eligible cases, the median patient age was 31.0 years (IQR 26.5-35.5) with 164 (52.1%) in the third trimester. Index images included 288 (91.4%) CTPA and 27 (8.6%) scintigraphy, 25 of which were low-dose perfusion scans. PE was diagnosed in 5 (1.6%), all by CTPA. Among 116 scintigraphy-eligible cases, CTPA was favored: 82.8% versus 17.2%, with similar patterns between ED and LDU clinicians. CTPA diagnosed pneumonia in 6 cases (2.1% of 288) not previously identified on CXR and excluded pneumonia in 5 cases in which CXR suggested consolidation. Indeterminacy was more common with non-positive CTPA (24.7% [70/283]) than non-positive scintigraphy (0% [0/27]), p < 0.001. Only 7.1% (5/70) of patients with suboptimal non-positive CTPA received advanced imaging within 48 h, and none of the remaining 65 patients developed VTE or died within 90 days. CONCLUSIONS: In this multicenter community setting with a low prevalence of PE, CTPA was preferentially ordered over lung scintigraphy in both the ED and LDU, even when both modalities were available and indicated. Indeterminate results were more prevalent with CTPA and often failed to trigger additional advanced imaging.
Hoffmann JA, Parikh TK, Lorenz D
… +39 more, Goldman MP, Powers EM, Patel SJ, Lavina IS, Heyming TW, England JT, Saidinejad M, Claudius I, Ghosh P, Shapiro DJ, Swan TB, Bouvay KL, Kurowski EM, Smith NM, Davis JR, Moxam AB, Muhrer EJ, Shenoi RP, Portillo EN, Kaplan RL, Uspal NG, Lapus RM, Vo AT, Fenster DB, Barrocas DB, Liu DR, Chaudhari PP, Cafferty R, Freedman SB, Rose JA, Evers MF, Metcalf AM, Saleh F, Dunnick J, Pitetti RD, Nathani YR, Waseem M, Florin TA, Pediatric Emergency Medicine Collaborative Research Committee (PEMCRC) Psychosis Study Group
Acad Emerg Med
· 2026 Jan · PMID 41025829
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BACKGROUND: The clinical utility of diagnostic neuroimaging for pediatric patients presenting to the emergency department (ED) for psychosis remains unclear. We sought to estimate the prevalence of and characteristics as...BACKGROUND: The clinical utility of diagnostic neuroimaging for pediatric patients presenting to the emergency department (ED) for psychosis remains unclear. We sought to estimate the prevalence of and characteristics associated with clinically significant neuroimaging findings among pediatric patients presenting to the ED with symptoms of psychosis who had neuroimaging performed. METHODS: This retrospective cross-sectional study included visits by patients 5 to < 18 years old presenting with symptoms of psychosis to 28 EDs affiliated with the Pediatric Emergency Medicine Collaborative Research Committee from 2016 to 2019 and had neuroimaging performed. We estimated the rate of clinically significant neuroimaging findings, defined as those resulting in further testing, treatment, or medical admission, overall and by imaging modality. Multivariable logistic regression models examined presenting features associated with clinically significant findings. RESULTS: Clinically significant neuroimaging findings were identified in 5.4% (95% CI 4.2%, 6.9%) of 1118 ED visits (54% male, median [IQR] 14 [11-16] years old). Clinically significant findings occurred in 4.9% (34/699) of head computed tomography scans and 7.5% (45/604) of brain magnetic resonance imaging studies (p = 0.07). In a model that imputed missing data, no presenting features were associated with clinically significant neuroimaging findings. In a model that treated missing documentation as absence of the clinical feature, the adjusted odds of clinically significant neuroimaging findings were lower among ED visits by patients with suspected alcohol or substance use (aOR 0.38, 95% CI 0.16, 0.87). CONCLUSION: Among pediatric patients presenting to the ED with symptoms of psychosis who had neuroimaging obtained, approximately 1 in 20 had clinically significant findings. Suspected alcohol or substance use was associated with lower odds of clinically significant neuroimaging findings, although this finding was not consistent across modeling approaches. Prospective studies are needed to definitively evaluate the utility of neuroimaging among children and adolescents presenting to the ED with symptoms of psychosis.
Lilien EJ, Ashburn NP, George TS
… +9 more, Snavely AC, Beaver BP, Costa CG, Chado MA, Cannon HA, Winslow JE, Nelson RD, Stopyra JP, Mahler SA
Acad Emerg Med
· 2026 Jan · PMID 40999766
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BACKGROUND: A single-dose epinephrine protocol (SDEP) for out-of-hospital cardiac arrest (OHCA) was recently found to have similar survival to hospital discharge (survival) rates compared to a multidose epinephrine proto...BACKGROUND: A single-dose epinephrine protocol (SDEP) for out-of-hospital cardiac arrest (OHCA) was recently found to have similar survival to hospital discharge (survival) rates compared to a multidose epinephrine protocol (MDEP). It remains unknown if survival rates vary for SDEP vs. MDEP by age. This study aims to determine if an SDEP protocol improves survival in distinct age groups. METHODS: We conducted a pre-post implementation study (MDEP vs. SDEP) in 5 North Carolina EMS systems from 11/01/2016-10/29/2019 among adult OHCA patients. Demographics and the outcome of survival were sourced from the Cardiac Arrest Registry to Enhance Survival. Patients were categorized as older (≥ 65 years), middle-aged (46-64 years), and young (18-45 years). Survival rates were compared pre vs. post SDEP implementation within age groups using Generalized Estimating Equations to account for clustering within EMS systems and adjust for sex, race, witnessed arrest, AED application, rhythm type, bystander CPR, arrest location, and EMS response time. The interaction of SDEP implementation with age group was evaluated. RESULTS: Among 1690 patients (899 MDEP, 791 SDEP), 864 were older, 538 were middle-aged, and 288 were young. Survival occurred in 13.6% (122/899) in the MDEP group and 15.4% (122/791) in the SDEP group. SDEP was associated with improved survival in older patients (12.2% [50/409] vs. 6.6% [30/455]; OR: 1.95, 95% CI 1.58-2.41) and similar survival in middle-aged (17.5% [47/268] vs. 18.2% [49/270]; OR: 0.96, 95% CI 0.53-1.25) and young (21.9% [25/114] vs. 24.7% [43/174]; OR: 0.88, 95% CI 0.41-1.90) patients. After adjusting, SDEP remained associated with improved survival among older adults (aOR: 1.87, 95% CI 1.36-2.56) and similar survival rates among middle-aged (aOR: 0.85, 95% CI 0.63-1.15) and young (aOR: 0.82, 95% CI 0.41-1.64) patients. The interactions of SDEP implementation between older and middle-aged (p = 0.001) and older and young (p = 0.05) patients indicate a differential effect. CONCLUSION: SDEP was associated with improved survival rates among older adults.
Qureshi E, Burstein B, Cummins K
… +4 more, Meckler G, Moe J, Miller SP, Doan Q
Acad Emerg Med
· 2025 Dec · PMID 40974016
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BACKGROUND: Programs redirecting patients with non-urgent presentations from Emergency Departments (EDs) to the community (ED2C), by providing them a booked community appointment in lieu of waiting for ED care, may reduc...BACKGROUND: Programs redirecting patients with non-urgent presentations from Emergency Departments (EDs) to the community (ED2C), by providing them a booked community appointment in lieu of waiting for ED care, may reduce ED crowding. We sought to evaluate the department- and patient-level impact of an ED2C program in an urban tertiary pediatric ED. METHODS: We conducted a matched cross-sectional study to describe patients redirected by a pediatric ED2C program and determine if the program changed ED operations. Days with the program were matched on day type (weekday vs. weekend) and department volume (±10%) to days when ED patients were not being redirected. Measures of ED flow and utilization on days with and without the program were compared using t-tests and linear regression models. RESULTS: Of the 6164 patients eligible for the ED2C program for 53 days that redirection was offered, 900 were redirected (14.6%). On average, 17.7 (SD 8.5) patients were redirected and 92.4 (SD 23.7) eligible patients were not redirected each day the ED2C was in operation. Patients who were redirected had a significantly shorter length of stay (LOS) than those who were eligible but not redirected (2.9 ± 2.0 h vs. 8.5 ± 4.3 h, p-value < 0.0001). Three patients who were redirected (0.3%) and 11 eligible but not redirected (0.2%) returned to the ED and were hospitalized. Average median departmental LOS, time to physician assessment, daily proportion hospitalized patients, proportion of patients left without being seen, and ED return visits did not differ on days with and without the program. CONCLUSIONS: A small proportion of eligible patients were redirected. These patients experienced a lower LOS, without increasing the proportion of return visits. ED operations were unchanged. Refining eligibility criteria for pediatric redirection with an emphasis on patient safety is necessary.
Diercks DB, Lall M, Messman A
… +5 more, O'Connell E, Hunt M, Karamatsu M, Pettit K, Courtney DM
Acad Emerg Med
· 2025 Dec · PMID 40944430
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BACKGROUND: Recent publications have shown that women are more likely to leave emergency medicine at a younger age than men. We aim to describe the prevalence of parental stress in academic emergency medicine and its ass...BACKGROUND: Recent publications have shown that women are more likely to leave emergency medicine at a younger age than men. We aim to describe the prevalence of parental stress in academic emergency medicine and its association with scheduling practices and desire to leave medicine. METHODS: Blinded survey sent to eight geographically diverse academic sites. Survey included five domains: academic rank and perception of progress, child and childcare characteristics, clinical scheduling practices, plans to leave medicine, and validated psychometric measures including the Parental Stress Scale (PSS: normal population score 35-45). Likert scale responses were dichotomized as either moderate/extremely likely versus less than moderately likely/unsure. Descriptive statistics were calculated, and linear and multivariate regression analyses were performed using STATA 16. RESULTS: A total of 280 surveys were accessed, and 225 (80%) surveys had PSS completed. Of this cohort, there were 90 females, 123 men, 1 intersex, and 15 surveys had no sex reported. The median number of children was 2 (IQR 1-3), and the median age of the youngest child was 4 (IQR 1-9). The parental stress scale median score was 40 (IQR 35-46). There was no significant difference in the parental stress scale by sex. The number of children (B-coeff -1.88, p = 0.007), age of the youngest child (B-coeff -4.2, p = 0.000), use of daycare (B-coeff 3.8, p = 0.027), ability to preference times of shifts (day, swing, night shift) (B-coeff -2.4, p = 0.046), being a nocturnist (B-coeff 2.75, p = 0.006), and being able to completely set their own schedule in terms of days and times worked (B-coeff -2.19, p = 0.03) were associated with the PSS score. The parental stress scale was not associated with the likelihood to leave emergency medicine or leave the current job in 5 years. CONCLUSION: Academic emergency physicians had parental stress scale scores similar to the general population. Parental stress scale score was not associated with a plan to leave emergency medicine.
Bolotin T, Subedi S, Dahal S
… +6 more, Walker C, Chung K, Martz A, Gemmel D, Chopra Q, Donley C
Acad Emerg Med
· 2025 Nov · PMID 40938265
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BACKGROUND: Morbidity and mortality in cardiogenic pulmonary edema have been reduced by noninvasive positive-pressure airway maneuvers. The value of continuous positive airway pressure (CPAP) for the treatment of high-al...BACKGROUND: Morbidity and mortality in cardiogenic pulmonary edema have been reduced by noninvasive positive-pressure airway maneuvers. The value of continuous positive airway pressure (CPAP) for the treatment of high-altitude pulmonary edema (HAPE) is uncertain. The purpose of this study was to evaluate the efficacy and speed of CPAP for HAPE resolution. METHODS: A prospective, investigator-initiated, multicenter, randomized, double-blind controlled trial of high-flow oxygen with CPAP versus sham CPAP with high-flow oxygen (oxygen-only group) was conducted. Sixty-four dyspneic adults with maximum oxygen saturation < 85%, recent arrival at high altitude, and noncardiogenic pulmonary edema on chest radiography were randomized to receive CPAP treatment plus usual care or usual care (oxygen-only) delivered through a sham CPAP mask. The primary endpoint was the clinical resolution of HAPE. RESULTS: HAPE resolution in the CPAP plus high FiO group and the high flow oxygen alone group was similar. However, this finding should be interpreted cautiously due to this study being slightly underpowered. There was no significant difference in time to resolution (CPAP ~158 min vs. oxygen ~178 min, p = 0.297). Both therapies were effective, with a mean time to resolution of HAPE of approximately 2.5 to 3 h. No treatment-related adverse outcomes, intubations, or mortality were observed in either group. CONCLUSION: Both CPAP with high-flow oxygen and high-flow oxygen alone are highly effective for the treatment of HAPE. CPAP conferred no improvement in the time to resolution of HAPE. High-flow oxygen therapy requires significantly less resource utilization for similar benefits in the treatment of HAPE. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04186598.